This progressive blog sets forth the personal views of the Dean of the Massachusetts School of Law on national events. Occasionally, the responses to his views or other interesting articles are also posted.

Wednesday, January 17, 2007

The Urgent Need For Information On The Results (I.e., The Outcomes) Of Medical Care

January 17, 2007

Re: The Urgent Need For Information On TheResults (I.e., The Outcomes) Of Medical Care.

From: Dean Lawrence R. VelvelVelvelOnNationalAffairs.com

Dear Colleagues:

Much in the news now is the question of medical care, including the issue of a single payer system, i.e., government run health insurance for all, as it is usually considered. Whether or not a single payer system is, after balancing its pros and cons, the most desirable solution for a major problem is something this writer does not know. But there is something relating to the health care system that I feel fairly confident about. Listen up, as they say.

Recently, I interviewed a University of Virginia professor for one hour about health care for MSL’s television show called Books Of Our Time. The professor, Elizabeth Teisberg, has co-authored a book called Redefining Health Care with Professor Michael Porter of Harvard. Remarkably, both Teisberg and Porter are business school professors, not doctors or medical school professors.

They have of course studied the health care system extensively and, as I understand it, they believe that their most important idea is that competition in medicine must be, as they might put it, restructured in order to provide better care at lower cost. Yes, better care at lower cost because, contrary to what is wrongly intuitive to Americans (one often sees something of the same phenomenon in higher education), more expensive does not always mean better. Sometimes less expensive is better because, as Teisberg and Porter believe about health care, less expensive can reflect experience, sometimes vast experience instead of merely little experience, can reflect better ways of doing things, and can reflect avoidance of wasteful, useless, but expensive treatments.

What would restructuring the health care system mean in practice, according to Teisberg and Porter? Without getting into all the numerous details, let me give an example. It involves what the authors call competition at the “medical condition” level. Suppose the issue is spinal injuries. As Teisberg and Porter describe it (if my understanding is correct), today doctors in different departments of a hospital will be involved in the treatment. They will be orthopods, radiologists, surgeons, anesthesiologists, and what not. This, the authors say, is not the way it should be done. Rather, a hospital should have a department dedicated to spinal problems, with all the necessary different kinds of specialists being a part of that department. This will give all of them more experience with and knowledge of the relevant kind of medical problem -- spinal problems -- will foster communication among the different specialists and thereby lead to better treatments, will create a body of knowledge among the different specialists about what treatments do or don’t work, will encourage desirable experimentation to discover better methods, and so forth. There should be similar specialty departments for heart problems, brain problems, diabetes, kidney problems and all sorts of “medical conditions.”

Teisberg and Porter say that not every hospital, clinic, etc. should attempt to have a specialty department for every “medical condition.” Rather, each should have specialties in what it can do well but not in other medical conditions. This will eliminate the horrendous cost of purchasing very expensive machines, used for particular medical conditions, that lie fallow too much of the time in given hospitals or clinics and, when used, are used by doctors who lack sufficient experience with the particular medical condition.

The competition in medicine, the authors say will be to provide both the best and least expensive care at the “medical condition” level -- the best and least expensive care for spinal problems, kidney problems, heart problems, etc., etc. Hospitals or clinics which provide the best care at the least cost will get the most business and, very importantly, other doctors and institutions will begin using (will find it competitively necessary to use) the practices which the successful ones have shown are the best to date.

Teisberg and Porter also say that their ideas are not out of the blue. Rather, there are institutions which have begun using those ideas, both ideas mentioned here already plus others discussed below. I must say that, since interviewing Teisberg, I have noticed occasional articles that would appear to bear out the claim that various institutions are adopting, or making use of, the pertinent ideas.

As said, the authors believe that their most important idea is that of competition at the medical condition level. That is why I’ve explained the idea, albeit briefly (and only as I best understand it). But presumptuous as it is for this writer to say so -- since I know so little about the subject -- one is not absolutely sure that the idea they think their most important is in fact their most important. For the existence of competition at the medical condition level depends on another factor which they extensively discuss and which is important to true competition (not the phony competition that so often prevails) in any field. It depends on information being available to the public on quality and cost. Information on quality and cost is the necessary fundament of true competition. Otherwise people are buying blind, are buying high cost items because advertising has persuaded them, etc.

Teisberg and Porter make clear that, currently, information about quality and cost of care is preeminently unavailable in the health care field. Doctors, clinics, hospitals, etc. are not required to assess the quality of the care they are providing -- i.e., the outcomes of that care -- or whether they are providing it less expensively or more expensively than other providers are. There are few statistics about these matters. So people don’t really know whether one cancer center is doing a better job than another (i.e., is achieving better outcomes), whether one heart center is doing a better job than another, whether a given surgeon is a disaster who loses a disproportionate number of patients, whether a given internist misdiagnoses patients at an unacceptably high level, etc. Patients don’t know this, nor do their family doctors who refer them to one specialist or hospital rather than another, nor do insurers or HMOs who pay doctors. In short, everyone is flying blind.

This might not matter if all doctors, hospitals, clinics, etc. were equal and therefore fungible. But differences in quality and results (i.e., medical outcomes) are staggering, are off the wall, if one is to believe Teisberg and Porter, as this writer surely does on this score because there are always vast differences among practitioners of any field. (There recently was an article, I think in The Boston Globe, which said that statistics about Massachusetts heart surgeons showed that there were some whose results (outcomes) were so much worse than others that they were “outliers” -- and had left the state. That there could be “outliers” of this kind and degree in heart surgery is frightening.) Because of the vast discrepancy in the quality of different providers (in their medical outcomes), it is obviously essential to hoped-for improvements in medicine that extensive statistics begin to be kept and made available. This will enable doctors and other medical advisers to refer patients to, and will cause patients to “patronize,” the better providers, who, if Teisberg and Porter are right, also will often be the less expensive ones because their quality will in part reflect experience and, in various ways, consequent efficiency. It likely will also cause “inferior” providers to clean up their acts, by emulating the techniques of the better ones out of both pride and the necessities of business.

The idea that there is a vast discrepancy in the quality of health care providers, and that statistical comparisons of quality (outcomes) and cost are basically unavailable in medicine today, leads to several questions or comments. Doctors, one gathers, are usually very intelligent persons these days. For decades, after all, medical schools have chosen from among the cream of the intellectual crop. Doctors also are said to work ungodly hours. How is it, then, that (aside from drunkenness) some of them practice at a level as low as is indicated by Teisberg and Porter? Well, Teisberg said in the TV interview that there is just too much information for doctors to keep up with it all. Even so, a layman is a little hard pressed to understand why differences in quality are so marked.

Then, too, there is the matter of the importance of statistical information on quality (outcomes) and cost becoming available regardless of what other types of improvements are made in the health care system -- regardless of whether doctors and institutions begin structuring their practices around and competing at the “medical condition” level, as the coauthors would like, whether we go to a single payer system (which the coauthors do not favor because they fear that consequent universally required rules would stifle innovation), or whether other changes are made. Whatever is done in health care, it seems to this writer, at least, that information on relative quality and cost is a sine qua non of improvement. Even in a single payer system, for example, you would want statistical analyses of quality (outcomes) and cost so that all providers could adopt the practices that work best, and may be less expensive as well.

Then there is the fundamental question of whether it is possible to develop the kinds of accurate statistical analysis of quality (outcomes) and cost that are needed. For decades, I think, medicine has often resisted comparisons of the quality of care because doctors don’t want to be shown up, and because of concern that the statistics could be misleading because, for example, a hospital (such as a teaching hospital) could show bad mortality rates, but that would be due to the fact it took the most difficult cases. Yet the difficulty of the cases would not be taken account of.

Teisberg and Porter say that it now is possible to produce “risk adjusted” figures on the quality of care (on outcomes), figures that by appropriate techniques take account of the differences in the difficulty of cases. They further claim that there already are some medical institutions which are doing this, say that the practice is increasing, and make suggestions as to the types of organizations which could appropriately create the metrics (e.g., organizations of medical specialties, insurers, health maintenance organizations).

To this writer, as said, the most crucial necessity in medical care is to begin making the needed information available to patients, referring doctors, medical advisers, the general public, etc. Just as in every other walk of life -- let me repeat that -- just as in every other walk of life, a lack of publicly available information, sometimes because of deliberate secrecy, leads to bad results (a fact which all are acquainted with when it comes to governmental matters of all types and to unethical and dishonest conduct by large corporations, and which some are acquainted with in other fields, e.g., accreditation of law schools or certain other types of institutions). If we want to improve the situation in the field of health care, it is essential, it seems to me, to vastly improve the amount of information that is publicly available about outcomes and costs.

Two last points. At various places in their book, Teisberg and Porter mention various institutions which, they say, create, to one degree or another, the kinds of information about outcomes that people need. At the end of the television interview, which will be shown on Comcast’s Channel 8 on Sunday, January 21st in New England and on a Sunday in February in the Mid-Atlantic states, our producers have listed the names, addresses, phone numbers and email addresses of the institutions that Teisberg and Porter mention. The producers have done this so that persons who want or need the information will have access to it. For the same reason, I have appended the list at the end of this posting.

Also, some might want to see the interview (because of the importance of the coauthors’ points and because, while I think I’ve got things right in this post, Teisberg is a far more knowledgeable expositor). For those who might want to see and hear what she has to say, the interview, in addition to being broadcast on Comcast’s CN8 on Sunday, January 21st, at 11:00 a.m. in New England and on a Sunday in February in the Mid-Atlantic states, will also be viewable in its entirety on the web as of Thursday, January 18th at noon. Go to Google, click on video, and then type the name of the program, Redefining Health Care.*

List Of Institutions That, According To Redefining Health Care, Create Analyses Of Medical Results (Outcomes) To One Degree Or Another

* This posting represents the personal views of Lawrence R. Velvel. If you wish to respond to this email/blog, please email your response to me at velvel@mslaw.edu. Your response may be posted on the blog if you have no objection; please tell me if you do object.

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About Dean Velvel

Name:Lawrence
Velvel

Location:Andover, Massachusetts,
United States

Dean Velvel, an honors graduate of
the University of Michigan Law School, has practiced law in the public and private sectors,
and been a law professor. He is the author of the quartet Thine Alabaster Cities
Gleam. The books in the quartet are entitled: Misfits In America, Trail of
Tears, The Hopes and Fears of Future Years: Loss and Creation, and The Hopes
and Fears of Future Years: Defeat and Victory.

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